My own jurisdiction is Newfoundland. Telehealth, which Bob mentioned, is being pioneered by a unit in Labrador, where they've had challenges delivering health care to rural communities. It has made a big difference. Again, it's a question of multiple strands to answer the problem.

On the concept of looking at funding models, in Alberta, for example, there is a system whereby funding can be attracted for the primary care networks. It goes to non-medical services for groups that agree to provide comprehensive care. That money allows them to provide walk-in clinics, on-site foot care clinics, diabetic counselling, nutritional counselling, and those kinds of things. Groups of doctors amalgamate under this umbrella of a primary care network.

To step back and ask what could be done at the federal level, I would take you back to the two issues of best practice and innovation. There is no comprehensive system for identifying loci of best practices. There are good things in Labrador, there are great things in Saskatchewan, and there's the urology practice in Saskatoon. There are wonderful things in Alberta and perhaps in Ontario, but that information doesn't get shared. There's no centre for best practice. The health council may have thought at one time that would be part of its mandate, and it kind of never went that way.

The other thing is innovation. How do you plant the seed and fund models that are trying something out? If you don't allow new ideas to bubble up and succeed or fail without prejudice, you'll never get any further than you are at the moment. The Canadian Medical Association would like to see the feds look at a centre for innovation. There has been some talk of that and some money suggested in that direction. We say that's a good start, and let's have some more.

So if you want to try to build a firmer foundation you need to have mechanisms to identify and promulgate best practices--areas where there's funding for innovative approaches along team lines, and that kind of thing. In actual fact, that was one of the things that fell out of the 2004 accord right back at the beginning. There was some money set aside for primary care reform, and that kick-started some team approaches in our province for the money that was produced there. So I'd offer that as a possible way ahead.

From a slightly different perspective, where fee for service is an issue with your question, in Ontario there is no provision for lower-income people to access chiropractic care and have it funded, since funding was withdrawn in 1994. That makes it difficult when you're looking after a population stuck at home, perhaps in poverty.

There are experimental clinics in many loci, as Dr. Haggie mentioned, where we're doing a salary-based approach that is covered by local associations, and you have a multi-disciplinary approach. That has had terrific reviews from the seniors and chronic-care patients. We're in the midst of work on a project in Nunavut as well--a multi-disciplinary project for that community. But again, the projects are not interconnected, they have not yet become the norm, and fees are a problem.

There are just three things I want to mention. First of all, we are certainly partnering with our other associations, and are very pleased with our recent collaboration with the CMA on transforming the health care system. There are documents out on that. Of course, everywhere CNA goes we advocate for an integrated home care and community-based system.

Another example that has recently been given is the PATH program. It stands for “partners advancing transitions in health care”, under the auspices of the Change Foundation. It is focusing on engaging and supporting a community coalition of providers, patients, and caregivers to redesign problematic care transitions--in other words, those where complexity is causing the ALC length of stay.

I would also like to talk to you as a health professional. We all agree that bad lifestyle choices contribute to a rise in chronic problems for seniors and adults alike. As health professionals, we tell our patients to eat healthier. Yet they continue to eat food that is bad for their health. We tell them to exercise and they do little or none. The same goes for smoking, for cigarettes; they continue to smoke for pleasure or for other reasons. At the end of the day, even though we have the best of intentions as health professionals, our recommendations and advice are not followed. In short, prevention is no easy task.

I would like to open this discussion and ask the representatives from all the associations, including the Canadian Geriatrics Society, what we can do. In addition to our good intentions, what can we do to really change the habits of our patients?

The most important thing is early diagnosis and treatment, first of all. It is having those screening programs in place where we pick up these diseases that are lifestyle-caused, or certainly exacerbated, and begin to recognize them.

Second, I would say that we need programs from the ground up. Our public health nurses in schools, for example, have been pulled back in many communities across Canada. We no longer have the robust program of school health that we may have had once, yet we must begin in infancy. We must begin with young children to teach them lifestyle ways.

Those are the two areas, and then, of course, there are the treatments throughout the life cycle upon which we need to focus.

Just to take up Barb's point a little bit, I would go back to the issue of education. Somebody once said “You give me the child, and I'll give you the man”. Essentially, if you go back to school and can become a health-literate graduate of high school, by which I mean someone who understands enough to navigate the information that's out there, you've probably done as much as you can.

The background to healthy eating is sometimes actually economic. I've worked in areas where it is cheaper to buy two bags of chips and a can of Coke than it is to buy a glass of milk and an apple. When you are on a very limited income—and I come from a province whose average income is lower than the Canadian average, and the population I refer to has a lower average income than that even—that makes a huge difference. You go with what will fill your belly on that day, not necessarily what's going to be good for you over the long term. A hungry kid at school is not going to learn, either, so a school breakfast program might be something you would want to think about.

I'm talking outside my field of expertise. I'm a general surgeon. I'm a disease expert, and I've gone right back to now talking about education and clean water and those kinds of things. That's just my two cents' worth, but I'm off my home patch.

I don't think I should be the poster child for problems with healthy living. That is a lifelong problem.

People tend to go toward pleasure and away from pain. That is pretty universal behaviour. So until the message either gets through well enough or people have a scare, they tend not to respond as well unless they are trained at an early level.

Perhaps we could look at two models. One is the anti-smoking program, which is finally showing good outcomes in youth, as there's a dropping rate of smoking now. And the other is the dental models. Again, that's based toward pleasure. People want to look good. In the chiropractic world we often say that if people's spines were in the front they'd pay more attention to them. As it is, they don't see them unless they are painful.

Perhaps looking at other successful models might be an approach. The thrust of our practice is always about capacity and how one functions, and people tend to only pay attention when they're in pain.

This is an area where it is appropriate to recognize that you have to understand how complicated it is to change people's behaviour. You can be neither naive nor excessively sophisticated. It is extraordinarily difficult to change behaviour.

The tobacco example is an outstanding one because the first evidence about the risk of tobacco began appearing in the literature around 1955. Yet it has come to now before we actually have the rates of tobacco consumption down to 15%. But we are still going to see lung cancer surpass breast cancer as a cause of cancer deaths for women, because the smoking rates spiked some 10 or 15 years ago.

These are disasters, and when they are that complicated you have to recognize that your whole society has to unify itself in its message to try to end up with change, because it isn't solely the human behaviour that's involved. Our environments facilitate us doing these things.

I think there is some partial credibility. There's probably an education effect. Many people who are bilingual may have a different educational level.

But there is also a possible cognitive stimulation level. As people switch back and forth between languages, they're cognitively stimulating themselves and using different parts of the brain and using the parts of the brain that are required to change association. So I think there is some validity to them.

Certainly, being a Canadian, I think it's a good idea to be bilingual, and I recommend it as a health care measure.